Rachel's Democracy & Health News #897, March 8, 2007


[Rachel's introduction: Human health is a prime indicator of environmental quality, and of the success of any society. If the health of residents is poor, then look for problems in the environment. If some groups are thriving and others are not, those health disparities are a sure sign of trouble -- and of injustice.]

By Peter Montague

Human health is a prime indicator of environmental quality, and of the success of any society. If the health of residents is poor, then look for problems in the environment. If some groups are thriving and others are not, it's a sure sign of injustice.

Such differences are called "health disparities" (or, sometimes, "health inequities"[1]) and the U.S. has set a goal of eliminating them.

There's a long way to go to meet that goal.

A recent study of longevity in the U.S. found that white "Middle Americans" live five years longer, on average, than black "Middle Americans" -- 77.9 years vs. 72.9 years. And this does not include "high-risk urban black men," who live, on average, only 71.1 years. The differences between "Middle American" racial groups are not explained by health insurance coverage or by frequency of medical appointments -- so access to medical care is not the primary driver of these disparities.

Hispanics are about twice as likely as non-Hispanic whites to have diabetes, or to get cancer of the stomach, liver, gall bladder, or cervix. Hispanic women develop heart disease about a decade earlier than non-Hispanic white women.

Two times more black women die in childbirth than white women. The nation's cancer death rate is 35 percent higher in black men and 18 percent higher in black women than in white men and women, according to a new report from the American Cancer Society. These facts barely scratch the surface.

How are 'health disparities' defined?

The National Association of County and City Health Officials (NACCHO) has defined "health disparities" as "differences in populations' health status that are avoidable and can be changed. These differences can result from social and/or economic conditions, as well as public policy. Examples include situations whereby hazardous waste sites are located in poor communities, there is a lack of affordable housing, and there is limited or no access to transportation. These and other factors adversely affect population health."

On paper at least, the U.S. is committed to eliminating health disparities.

** The federal Department of Health and Human Services has established an Office of Minority Health with a "National action agenda to eliminate health disparities for racial and ethnic minority populations."

** The federal program, Healthy People 2010, has two goals: "(1) Increase quality and years of healthy life; and (2) Eliminate health disparities, including differences that occur by gender, race or ethnicity, education or income, disability, geographic location, or sexual orientation."

** The American Public Health Association has called for action to eliminate health disparities.

** NACCHO -- The National Association of County and City Health Officials -- has passed a strong resolution advocating for programs and policies that minimize health inequities;

** NACCHO has published standards that every local health department (LHD) should be able to meet: "These standards describe the responsibilities that every person, regardless of where they live, should reasonably expect their LHD to fulfill." The NACCHO standards say, "...all LHDs (local health departments) exist for the common good and are responsible for demonstrating strong leadership in the promotion of physical, behavioral, environmental, social, and economic conditions that improve health and well-being; prevent illness, disease, injury, and premature death; and eliminate health disparities."

** The national Society for Public Health Education in 2002 passed a "Resolution for Eliminating Racial and Ethnic Health Disparities."

Health disparities can be eliminated by prevention

Health disparities are difficult (or impossible) to remedy once they have been allowed to develop. However, they can be prevented.

A recent report from the Prevention Institute in Oakland, California describes steps that communities can take to eliminate health disparities through prevention.

The "main premise" of the report is that, "reducing disparities can only be achieved if attention is paid to eliminating and minimizing diseases and injuries before the need for treatment, therapy, and disease management, and this can only be done by changing fundamental conditions of the environment that arise from racial and economic injustice." And: "Eliminating racial and ethnic health disparities is imperative both as a matter of fairness and economic common sense."

The Prevention Institute has identified 13 "community factors" that "play a pivotal role in determining health and disparities." (pg. iii)

The report then offers 10 disparity-reducing strategies that public health practitioners, advocates and decision-makers can focus on. This is good stuff -- grounded in the scientific and medical literature, yet very practical. The Prevention Institute even has a "community assessment tool" -- called Thrive -- that everyone can apply in their own community begin to prevent health disparities.

The 13 "community factors" are organized into 3 clusters:

1. The Equitable Opportunity Cluster: the equitable distribution of opportunity and resources

a. Availability of jobs paying living wages -- individual income alone has been shown to account for nearly one-third of health risks among blacks. The remainder may be explained by residential segregation, which locks people into poor housing, neighborhoods without recreational opportunity or access to nutritious food, and so on.

b. Education -- high school dropout rates correlate closely with poor health. Lower education levels are associated with smoking, overweight, and low levels of physical activity.

c. Racial justice -- racial and ethnic discrimination are harmful to health. Economic inequity, racism, and oppression can maintain or widen gaps in socioeconomic status, and increase stress.

2. The People-Factors Cluster

d. Social networks and trust: "strong social networks and connections correspond with significant increases in physical and mental health, academic achievement, and local economic development, as well as lower rates of homicide, suicide, and alcohol and drug abuse." (pg. 9)

e. Participation and willingness to act for the social good: "Social connections also contribute to community willingness to take action for the common good which is associated with lower rates of violence, improved food access, and anecdotally with such issues as school improvement, environmental quality, improved local services, local design and zoning decisions, and increasing economic opportunity. Changes that benefit the community are more likely to succeed and more likely to last when those who benefit are involved in the process; therefore, active participation by people in the community is important."

f. The behavioral norms within a community, "may structure and influence health behaviors and one's motivation and ability to change those behaviors." Norms contribute to many preventable social problems such as substance abuse, tobacco use, levels of violence, and levels of physical activity. For example, traditional beliefs about manhood are associated with a variety of poor health behaviors, including drinking, drug use, and high-risk sexual activity.

3. The Place-Factors Cluster

This refers to the physical environment in which people live, work, play, pray and go to school. This includes:

g. What's sold and how it's promoted. The presence of a supermarket in a neighborhood increases the consumption of fruits and vegetables by more than 30%. The presence of many liquor stores is associated with greater liquor consumption which in turn is linked to increased violence. If large portions of high-fat, high-sugar junk food are aggressively marketed, that's what people tend to eat.

h. Neighborhood look and feel, and safety. "The physical space of communities influences patterns of life. The distances between home and work, the look and feel of a streetscape, the presence or lack of retail stores and parks influence whether people drive, walk, or bike and how they spend their leisure time.All too often, residents in low- income communities cope with inadequate sidewalks, inadequate access to public transportation, absence of bike lanes for cyclists, absence of walking and biking trails and absence or ill maintenance of parks, along with inaccessible recreational facilities and crime. Safety is a dominant concern leading parents to drive their children to school, rather than letting them walk, and to prohibit outdoor play." (pg. 12)

i. Parks and open space. Physical activity levels -- and positive interactions between neighbors -- are influenced by enjoyable scenery, greenery, access to parks, convenient transportation, and the design of streets and neighborhoods.

j. Getting around. "A well-utilized public transit system contributes to improved environmental quality, lower motor vehicle crashes and pedestrian injury, less stress, decreased social isolation, increased access to economic opportunities, such as jobs, increased access to needed services such as health and mental health services, and access to food, since low-income households are less likely than more affluent households to have a car."

k. Housing. Poor housing contributes to health problems in low-income communities and communities of color and is associated with increased risk for injury, violence, exposure to toxins, molds, viruses, and pests, and psychological stress.

l. Air, water, and soil. "Low-income communities and communities of color are more likely to have poor air quality and toxic brownfield sites. Poor air quality prevents individuals from engaging in physical activity, especially if they have asthma or other respiratory illnesses. Contaminated empty lots, which could serve as badly needed parks and open space, frequently require large sums of money for sufficient clean-up.... Cancer, asthma, birth defects, developmental disabilities, infertility, and Parkinson's disease are on the rise, and they are linked to chemical exposures from air, water and soil, and products and practices used in our schools, homes, neighborhoods, and workplaces. Low-income people and people of color are typically the most affected by environmental health concerns."

m. Arts and culture. "The presence of art and other cultural institutions contributes to an environment that is conducive to health and safety. Artistic outlets, such as gardens, murals, and music, promote a healing environment. This has been demonstrated in hospitals and other health care facilities, where the incorporation of arts into the building's spaces has reduced patient recovery time and assisted in relief for the disabled, infirm, or their caregivers. The visual and creative arts enable people at all developmental stages to appropriately express their emotions and to experience risk taking in a safe environment. For those who have witnessed violence, art can serve as a healing mechanism. More broadly, art can mobilize a community while reflecting and validating its cultural values and beliefs, including those about violence. Also, artistic expression can encourage physical activity, as in the case of dance. A report commissioned by the Ottawa City Hall states that culture "provides benefits in terms of...social cohesion, community empowerment... health and well being and economic benefit."[2]

So there you have it -- 13 community factors that strongly determine health disparities. Next week we'll discuss 10 disparity-reducing strategies that communities can use.

Meanwhile, here's one final thought. Health disparities go to the heart of "environmental health." Eliminating health disparities will take us in some new directions. As the Prevention Institute report says (pg. 22),

"This approach to improving health outcomes necessarily requires that the public health sector and health advocates approach health in a new way. It requires a new way of thinking and a new way of doing business. This is not an approach that identifies a medical condition and asks,"How do we treat this?" Rather, it requires understanding how the fundamental root causes of health disparities play out in the community in a way that affects health and asking, "Who do we need to engage and what do we need to do in order to prevent people from getting sick and injured?"

More next week.


[1] Dennis Raphael, "Health Inequities in the United States: Prospects and Solutions," Journal of Public Health Policy Vol. 21, No. 4 (2000), pgs. 394-427. Available here: 3.5 Mbyte PDF.

[2] Excerpted from Rachel Davis, Larry Cohen, and Leslie Mikkelsen, Strengthening Communities: A Prevention Framework for Reducing Health Disparities." Oakland, Calif.: Prevention Institute, 2003, pg. 18.